Nursing Fundamentals and Assessment Practice Flashcards

Theoretical Foundations of Nursing

Florence Nigthingale introduced the Environmental Theory, emphasizing the key concepts of night and light and the profound influence of physical surroundings on health and recovery. Virgina Henderson defined the 14 Basic Needs of the individual, asserting that the primary purpose of nursing care is to help the patient gain independence as rapidly as possible. Dorothea Orem developed the Self-Care Deficit Theory, focusing on an individual's capacity to meet their own care needs and identifying clinical interventions required when a deficit occurs. Hildegard Replan formulated the Theory of Interpersonal Relations, centering on patient-nurse communication and therapeutic dynamic interactions. Callista Roy created the Adaptation Model, which examines role adaptation and how individuals constantly adjust to environmental stimuli. Martha Rogers authored the Science of Unitary Human Beings, describing human beings in terms of dynamic radiation and energy fields integral with the universe.

Jean Watson established the Theory of Human Caring, highlighting the essential role of warm care and humanistic connections in health promotion. Betty Neuman designed the System Model, which addresses how the nervous system and bodily equilibrium react to stress and environmental stressors. Imogene king established the Goal Attainment Theory, asserting that nurses and clients interact to identify key goals mutually and work collectively to achieve them. Madelaine Leininger developed Transcultural Nursing, emphasizing that language and culture are critical factors in delivering holistic and effective patient care. Lydia Hall developed the Care, Core, Cure model, focusing on nursing care, therapeutic self-awareness, and medical treatment leading to healing. Faye Glenn Abdellah established the 21 Nursing Problems framework to systematically assess problems and guide clinical nursing judgment. Myra Levine formulated the Conservation Model, centered on life conservation through preserving energy, structural integrity, personal integrity, and social integrity.

Abdominal and Visual Physical Examinations

Abdominal assessment must follow a strict sequential order summarized by the acronym I APP: Inspection, Auscultation, Percussion, and Palpation. Auscultation is performed prior to percussion and palpation to ensure that bowel sounds are captured without artificial stimulation from physical manipulation. Bowel sounds should be evaluated over a duration of $5\text{ to }20\,\text{mins}$. The examination sequence across the abdominal quadrants begins in the Right Lower Quadrant (RLQ), moving to the Right Upper Quadrant (RUQ), then to the Left Upper Quadrant (LUQ), and finishing in the Left Lower Quadrant (LLQ) (\text{RLQ} > \text{RUQ} > \text{LUQ} > \text{LLQ}). Hyperactive bowel sounds indicate diarrhea, whereas hypoactive bowel sounds indicate constipation. The presence of rebound tenderness during palpation is a key clinical sign indicative of appendicitis.

Visual acuity assessment utilizes the Snellen Chart with the patient positioned at a distance of $20\,\text{ft}$ away from the chart. The assessment procedure tests both eyes simultaneously first, followed by testing the right eye (R eye), and then the left eye (L eye). A standard normal vision finding is documented as $20/20$.

Auditory Examination and Tuning Fork Assessments

Physical examination of the ears combines visual inspection and otoscopic evaluation. For adult patients, the outer ear pinna is pulled up and back. For pediatric patients under three years of age (<3\,\text{y/o}), the pinna is pulled down and back. Specialized auditory testing incorporates a vibrating tuning fork to evaluate sound transmission to the ear. Sound travels via two primary mechanisms: through the air, which represents the normal conduction pathway, and through the bone of the skull. Two distinct tuning fork procedures compare these transmission pathways: the Rinne Test and the Weber Test.

The Rinne Test evaluates and compares Air Conduction (AC) relative to Bone Conduction (BC). The procedure begins by striking the tuning fork to initiate vibration and placing the base against the mastoid bone behind the ear, allowing the patient to hear sound conducted through the bone. As soon as the patient indicates that sound is no longer audible, the vibratingtines are moved directly in front of the ear canal to evaluate air conduction. A normal test result demonstrates that air conduction is heard longer than bone conduction (\text{AC} > \text{BC}). For example, if a patient perceives bone conduction for $5\,\text{seconds}$ on the mastoid bone and subsequently perceives air conduction for $10\,\text{seconds}$ in front of the ear canal, the result is documented as normal.

The Weber Test determines sound lateralization by evaluating which ear hears sound louder. The examiner strikes the tuning fork and places its base firmly on the middle of the forehead. The patient is asked to report where the sound is perceived. Normal results demonstrate equal sound perception in both ears. Abnormal findings include hearing the sound louder in the left ear or louder in the right ear.

Clinical Client Positioning Guidelines

Specific client positioning protocols are selected based on hemodynamic status, respiratory needs, surgical exposure, and aspiration prevention. Trendelenburg position involves tilting the entire bed body down with the head lower than the feet, utilized primarily for pelvis surgery and managing shock. Reverse Trendelenburg position tilts the bed with the head elevated above the feet, aiding breathing mechanics and helping reduce intracranial pressure (ICP). Modified Trendelenburg position elevates the legs while keeping the upper body flat, specifically implemented to address hypotension. Left Lateral Trendelenburg position is utilized to prevent aspiration and provide optimal surgical exposure.

General body positions support diagnostic, therapeutic, and comfort interventions. Supine position involves lying flat on the back, used for sleep, standard physical examination, and post-operative recovery. Prone position involves lying face down (Padapa), utilized for back procedures and to improve oxygenation. Sims position involves lying on the side with the top leg flexed, used for enema administration and rectal examination. Lithotomy position places the patient on their back with feet supported in stirrups, utilized during labor and vaginal examinations. Knee-Chest position involves resting on the knees and chest, used for rectal examination and sigmoidoscopy.

Respiratory and comfort positions focus on expanding lung volume and easing breathing difficulty. Fowler's position elevates the head of the bed between $30^\circ$ and $45^\circ$, providing comfort during eating, feeding, and cardiac management. Semi-Fowler's position provides a slightly elevated head angle of $30^\circ$ (WT $30^\circ$), supporting basic breathing assistance and cardiac care. High-Fowler's position involves elevating the head of the bed high between $60^\circ$ and $90^\circ$ (WT $60^\circ$), specifically used during nasogastric tube (NGT) insertion, feeding, and managing significant dyspnea. Orthopneic or Tripod position utilizes three points of support while aligning the spinous process of the 10th thoracic vertebra ($\text{T10}$), facilitating maximum lung expansion, dyspnea relief, management of respiratory distress, and eating comfort.

Professional Nursing Roles

Nurses perform key professional roles within client care and healthcare systems:

1. Caregiver: Takes care of sick people and makes them feel better.

2. Teacher: Teaches people how to stay healthy.

3. Counselor: Listens and helps when someone feels sad or worried.

4. Change Agent: Speaks up for patients to make sure they are treated fairly.

5. Client Advocate: Helps improve hospitals so patients get better care.

6. Manager: Leads and organizes other workers in the hospital.

7. Researcher: Participates in research to improve the quality of patient care.

Vital Signs Measurement and Interpretation

Vital signs assessment parameters are remembered using the acronym BROT P:

1. Blood Pressure (BP): Normal baseline is $120/80\,\text{mmHg}$. Systolic pressure measures heart contraction force, whereas diastolic pressure measures heart relaxation state.

2. Respiratory Rate (RR): Normal range is $12-20\,\text{bpm}$. Tachypnea is defined as a rate greater than >20\,\text{bpm}, and bradypnea is defined as a rate less than <12\,\text{bpm}.

3. Pulse Rate / Heart Parameters: Normal pulse rate range is $60-100\,\text{bpm}$. Tachycardia is defined as a heart rate greater than >100\,\text{bpm}, and bradycardia is defined as a heart rate less than <60\,\text{bpm}. Assess the apical pulse prior to administering digoxin.

4. Temperature: Normal core body temperature ranges from $36.5 - 37.5\,^\circ\text{C}$ or $97.7 - 99.5\,^\circ\text{F}$. The rectal route provides the most accurate temperature reading, whereas the axillary route is the least accurate.

5. Pain: Evaluated on a scale from $0\text{ to }10$.

Mechanisms of Human Body Heat Loss

Thermoregulation involves four distinct physical mechanisms through which the body transfers heat to the environment:

1. Conduction: Heat transfer occurring through direct contact or touch. Clinical examples include holding cold metal or lying directly on a cold floor.

2. Convection: Heat loss mediated by air movement or a current of air. Clinical examples include a fan blowing air directly on the body or cold outdoor wind removing body heat.

3. Radiation: Heat loss through space occurring with no direct contact. Clinical examples include an infant placed in a cold nursery room or sitting near a cold wall and feeling colder.

4. Evaporation: Heat transfer occurring as liquid converts into vapor (E-Vapor). The primary clinical example is a patient sweating during a fever episode.

Religious Beliefs and Dietary Considerations

Healthcare practice must accommodate religious dietary rules and medical restrictions:

1. Seventh-day Adventist: Strictly prohibits meat, alcohol, and coffee. No surgical procedures are to be scheduled during the Sabbath.

2. Baptist: Strictly prohibits alcohol.

3. Buddhist: Strictly prohibits alcohol and drugs. Many followers practice strict vegetarianism.

4. Roman Catholic: Abstinence from meat is required on Ash Wednesday and Good Friday.

5. Mormon: Strictly prohibits meat, alcohol, and coffee.

6. Hinduism: Beef consumption is strictly prohibited (bawal).

7. Islam: Strictly prohibits pork and alcohol. All consumed meat must be HALAL.

8. Jehovah's Witness: Prohibits blood products and foods containing blood (such as dinuguan).

9. Judaism: Strictly prohibits pork and the mixing of meat and milk. Meat must be ritually prepared according to kosher laws.

Comprehensive Pain Assessment Modalities

Pain assessment tools are selected based on client age, cognitive development, and communication ability:

1. Numeric Rating Scale: Utilized for adult patients who are verbal and capable of understanding numerical concepts. The patient selects a number from $0\text{ to }10$ representing their current pain intensity:

• $0$: None

• $1-3$: Mild

• $4-6$: Moderate

• $7-9$: Severe

• $10$: Worst

1. Wong-Baker FACES Pain Scale: Utilized primarily for pediatric patients. The nurse displays the faces chart to the child and explains: "Ito yung mga faces. Piliin mo kung alin ang mukha na parang nararamdaman mong sakit." The child points to the face matching their perceived pain, and the nurse records the corresponding value:

• $0$: No Hurt

• $2$: Hurts Little Bit

• $4$: Hurts Little More

• $6$: Hurts Even More

• $8$: Hurts Whole Lot

• $10$: Hurts Worst

1. FLACC Scale: Utilized specifically for infants, young children, and non-verbal patients unable to self-report pain.